Using a longitudinal multi-method approach to document, assess, and understand adaptations in the Veterans Health Administration Advanced Care Coordination program

Abstract

BackgroundUnderstanding adaptations supports iterative refinement of the implementation process and informs scale out of programs. Systematic documentation of adaptations across the life course of programs is not routinely done, and efficient capture of adaptations in real world studies is not well understood.MethodsWe used a multi-method longitudinal approach to systematically document adaptations during pre-implementation, implementation, and sustainment for the Veteran Health Administration (VA) Advanced Care Coordination program. This approach included documenting adaptations through a real-time tracking instrument, process maps, Implementation and Evaluation (I&E) team meeting minutes, and adaptation interviews. Data collection was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) enhanced framework for reporting adaptations and modifications to evidence-based interventions (FRAME) model. Adaptations were evaluated across 9 categories, and analytic team consensus and member-checking were used to validate the results.ResultsA total of 144 individual adaptations were identified across two implementation sites and the four data sources; analytic team consensus and member-checking processes resulted in 50 unique adaptations. Most adaptations took place during the early implementation and mid-implementation phases and were: 1) planned; 2) made to address changes in program delivery; 3) made to extend a component; 4) related to the core component of the intervention concerning notification of the community emergency department visit; 5) initiated by the entire or most of the I&E team; 6) made on the basis of: pragmatic/practical considerations; 7) made with an intent to improve implementation domain (to make the intervention delivered more consistently; to better fit the local practice, patient flow or Electronic Health Record (EHR) and/or for practical reasons); 8) a result of internal influences; 9) perceived to impact the RE-AIM implementation dimension (consistent delivery of quality care or costs). I&E team meeting minutes and process maps captured the highest numbers of unique adaptations (n = 19 and n = 13, respectively).ConclusionOur longitudinal, multi-method approach provided a feasible way to collect adaptations data through engagement of multiple I&E team members, allowing and a broader understanding of adaptations that took place. Recommendations for future research include pragmatic assessment of the impact of adaptations and meaningful data collection without overburdening the implementing teams and front-line staff.

Implementation science for cancer control: One center’s experience addressing context, adaptation, equity, and sustainment

“…Of note, PRISM highlights the importance of both (i) representativeness or equity on all RE-AIM outcomes; and (ii) equitable representation of all vested parties throughout program planning, delivery, evaluation, and dissemination. These guides have been used to assess context for primary care based lung cancer screening [ 26 ] and are for shared decision-making in oncology clinics.…”

“…Finally, we developed multi-method adaptation assessment and tracking methods. These include interview guides [ 10 ], progress notes, and coding systems designed to be used across planning, implementation, and sustainment phases of a program [ 18 , 26 , 35 ]. Our methods are designed to be low burden and to integrate Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) and Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) categories [ 36 , 37 ] with our RE-AIM framework.…”

Application of the FRAME-IS to a Multifaceted Implementation Strategy

“…2 ). ( 24 – 26 ) Text was extracted from the meeting minutes, narrative reports, and worksheets according to the FRAME-IS modules and inputted into a master matrix for content analysis. Two members of the research team independently entered the raw text data into the matrix from each source.…”

Application of the FRAME-IS to a multifaceted implementation strategy

“…We followed best practices from previous research to code and categorize adaptations across the three data sources (Fig. 2) [24][25][26]. Text was extracted from the meeting minutes, narrative reports, and worksheets according to the FRAME-IS modules and inputted into a master matrix for content analysis.…”